The ASCEND Study: Strategies to Reduce the Social Gradient in Bowel Cancer Screening

Funder

Amount

Duration

National Institute for Health Research

£1,111,826

Mar 2011 - Mar 2015

Background

Bowel cancer is the second commonest cause of cancer death in the UK.

Early diagnosis improves survival and in the light of this the NHS has
established the Bowel Cancer Screening Programme (BCSP).

The BCSP offers screening using a stool testing kit (the faecal occult
blood test or FOBt) to 60-69 year olds (and is being extended to include those
up to 74 years), every two years. Five regional Hubs co-ordinate the Programme.

Recent data show that only 53% of those offered screening take it up and
that this varies from more than 60% in the most socially advantaged areas of the
country to less than 35% in the most disadvantaged areas.

Aim

To reduce socio-economic inequalities in bowel
cancer screening uptake in England without compromising uptake in any
socio-economic group.

Objectives

Work stream 1: To explore psycho-social and cultural
determinants of low uptake of the gFOBt in the general population and in South
Asian communities.

Work stream 2: To develop and test four theoretically-based
interventions designed specifically to reduce the socio-economic gradient in
bowel cancer screening uptake.

Work stream 3: To use a RCT design to evaluate the effectiveness
and cost effectiveness of each individual intervention within the BCSP.

We conducted 18 focus groups with individuals
eligible for screening and from a range of socio-economic backgrounds in London
and South Yorkshire, in order to explore reasons for non-uptake of bowel cancer
screening.

In addition, we carried out interviews with
individuals who acted as key informants for a diverse number of South Asian
communities in London. South Asian communities were chosen because they make up
the largest ethnic minority group in England (approximately 7% of the
population). Key informants were purposively sampled to ensure representation
from the three dominant faith backgrounds (Islam, Hinduism and Sikhism).
Interviews were recorded, transcribed and analysed using thematic
analysis.

We designed a leaflet summarising the key screening
information in language suited to respondents with lower health literacy, and
we tested the leaflet for readability and comprehensibility via a number of
small qualitative studies with users. We
then conducted a multi-centre parallel RCT with screening-naïve individuals
(N=4452), to examine the impact of the leaflet on intentions to complete
screening.

We conducted 20 narrative style interviews with
individuals who had some experience of taking part in bowel cancer screening,
in order to produce a narrative leaflet based on their ‘stories’. We designed the leaflet and tested it via a
number of focus groups and interviews. We then conducted a RCT with
screening-naïve individuals (N=4125), to examine the impact of the leaflet on
screening intentions.

Intervention 3: General Practice Endorsement

This intervention involved inserting an additional
line of text of endorsement by the individual’s GP that would appear on the
BCSP invitation materials. We then invited all GPs across England to endorse
the BCSP.

Intervention 4: Enhanced Reminder

We developed text to be included in an Enhanced
Reminder letter to be sent as part of the BCSP screening invitation
materials. The text aimed to address
specific concerns that inhibit test completion particularly among those with
lower socio-economic circumstances, including lack of awareness of bowel cancer
and lack of perceived benefits of bowel cancer screening.

National, cluster-randomised trials compared ‘usual
care’ with each of the four intervention strategies (summarised in work stream
2) designed to target known barriers to uptake among people with lower socio-economic
circumstances.

Palmer CK. An overview of the ASCEND study and a focus on the
qualitative work re focus groups with non-responders. (Presentation) Bowel
Cancer Screening Programme health improvement team for Greater Manchester,
Bolton 2013.